The Code of Medical Ethics for the Korean Academy of Child and Adolescent Psychiatry: Why Is It Important?

This article provides an overview of the developmental history and rationale of medical ethics to establish the code of ethics and professional conduct of the Korean Academy of Child and Adolescent Psychiatry (KACAP). Most medical professional organizations have their own codes of ethics and conduct because they have continuous responsibility to regulate professional activities and conducts for their members. The Ethics and Award Committee of the KACAP appointed a Task-Force to establish the code of ethics and conduct in 2012. Because bioethics has become global, the Ethics Task Force examined global standards. Global standards in medical ethics and professional conduct adopted by the World Medical Association and the World Psychiatric Association have provided the basic framework for our KACAP's code of ethics and professional conduct. The Code of Ethics of the Americal Academy of Child and Adolescent Psychiatry has provided us additional specific clarifications required for child and adolescent patients. The code of ethics and professional conduct of the KACAP will be helpful to us in ethical clinical practice and will ensure our competence in recognizing ethical violations.

Validity and Reliability of the Korean Version of the Hamilton Depression Rating Scale(K-HDRS) / 신경정신의학

OBJECTIVES: The reliability and validity of the Korean version of Hamilton Depression Rating Scale (K-HDRS) were examined in Korean patients depressive symptoms. METHODS: 33 inpatients and 70 outpatients diagnosed as major depressive disorder or depressive episode of bipolar I disorder according to the DSM-IV criteria were assessed with K-HDRS, Clinical Global Impression score(CGI), Beck Depression Inventory (BDI) and Montgomery-Aberg Depression Rating Scale (MADRS). RESULTS: Internal consistency (Cronhach's alpha coefficeint=0.76) and interrater reliability (r=0.94, p<0.001) were statistically significant. Principal axis factoring analysis revealed 4 factors that accounted for 50.4% of the total variance. The correlations of K-HDRS with CGI, BDI and MADRS were 0.84, 0.54, 0.58 respectively. CONCLUSION: These results showed that the K-HDRS could be a reliable and valid tool for the assessment of depressive Korean patients. The K-HDRS will be a useful tool for assessing depressive symptoms in Korea.

Past, Present, and Future of Academic Conference in Korean Neuropsychiatric Association / 신경정신의학

The Korean Neuropsychiatric Association (KNPA) was founded in 1945 and has now grown to over 2000 members as of 2003. The Association's academic meeting has also been increasing in size every year. To further develop the academic meeting of the KNPA, the task force team conducted this project. We suggest several points based on analysing the abstracts of the meeting that has been conducted during the last 5 years, the survey results performed at the 2002 annual meeting, the annual meeting of the American Psychiatric Association, and the academic activities of a Korean medical assoction, the Korean Society of Otolaryngology.

Hypothalamic-Pituitary-Adrenal Reactivity in Boys with Attention Deficit Hyperactivity Disorder

The hypothesis 'whether subjects with attention-deficit/ hyperactivity disorder (ADHD), who showed under-reactivity of the hypothalamic-pituitary-adrenal (HPA) axis to stress, would make more commission errors in attention tasks', was examined. Forty-three boys, with ADHD, who visited the psychiatric outpatient clinic, at Kangbuk Samsung Hospital, were the subjects of this study. Both pre- and post-test morning saliva samples were collected from the patients at the Korean Educational Development Institute-Wechsler Intelligence Scale for Children (KEDI-WISC), and Tests of Variables of Attention (T.O.V.A.) performed. The Standard scores of the T.O.V.A were compared between the patients with decreases, or increases, in the salivary cortisol levels after the test. Decreases, or increases in the salivary cortisol levels after the test were shown in 28 and 15 patients, respectively. The patients with decreased cortisol levels after the test tended to make more commission errors in compared with those with increased cortisol levels. The patients with the decreased cortisol levels after test had more omission errors in the first quarter of the test, and more commission errors in the second half of the test compared to those with the increased cotisol levels. Subjects who show decreased salivary cortisol levels after stress make more commission errors in attention tests. This suggests that the blunted HPA axis response to stress is related to the impulsivity in patients with ADHD.

Dopamine Transporter Genotype Influences the Attention Deficit in Korean Boys with ADHD

Attention appears to be inheritable, stable and influenced by genetic factors. The use of the Continuous Performance Test (CPT), as an endophenotypic measure, is valuable for genetic studies because it may show increased sensitivity to specific dimensions in attention deficit hyperactivity disorder. However, few studies have been designed to examine the influence of the genotype on attention level measured by CPT in ADHD patients. This study examinee the difference between 10/10 and 10/* genotype in the attention deficits measured by the CPT in ADHD patients. Forty-four unrelated ADHD patients were recruited from the psychiatric outpatients' clinic at Kangbuk Samsung Hospital. Two child psychiatrists made the diagnoses of ADHD using the DSM-IV diagnostic criteria. The genomic DNA was extracted from the blood, and analyzed to determine the genotype. A 40-base pair variable number of tandem repeats (VNTR) polymorphism in the 3' untranslated region was amplified. The attention deficits were measured by the test of variables of attention (T.O.V.A.). Between the 10/10 genotype and 10/* genotype, standard scores of the T.O.V.A were compared using a Mann-Whiney test. A comparison with the 10/10 genotype and 10/* genotype showed that those patients with the 10/10 genotype made less omission errors in the first quarter of the test (p < 0.05, by Mann-Whiney test). No significant differences were observed in the errors of commission, response time, variability. This study found that the 10/10 genotype made less omission errors on the T.O.V.A. This suggests that the dopamine transporter genotype influences the attention deficits measured by T.O.V.A.

A Study of Relationship between Adolescent Attachment Patterns and Parenting Behaviors / 신경정신의학

OBJECTIVES: The purpose of this study is to investigate the Korean adolescent attachment patterns and their relations to parenting behaviors. METHODS: The subjects of this study were 792 high school students in Seoul. We assessed parenting behaviors perceived by adolescents and attachment type and quality of using Parenting Behavior Inventory, Self-report Attachment Style and Revised Adult Attachment Scale. RESULTS: 1) On the attachment pattern of adolescent, it revealed that 47.6% of the subjects were classified as "secure", 32.2% as "preoccupied", 14.6% as "dismissing" and 5.6% as "fearful". 2) The parental neglect was related to fearful and preoccupied patterns and parental inconsistency was related to preoccupied pattern. In terms of attachment quality and parental behavior, more parental affection and reasoning were related with more reliance. And more affection and less intrusiveness, neglect, and inconsistency were related with more closeness. More affection and reasoning and less physical abuse, intrusivenes, over-expectation, neglect, inconsistency were related with less anxiety. CONCLUSIONS: This study shows that adolescent attachment pattern would be transitional compared with that of infancy and adult. More positive parenting behavior such as affection and reasoning, and less negative parenting behavior such as physical abuse, intrusiveness, neglect, inconsistency were related with secure attachment pattern. Also, less positive parenting behavior such as affection and reasoning, and more negative parenting behavior such as physical abuse, intrusiveness, neglect, inconsistency were related with insecure attachment patterns.

The Development of a Korean Version of the Strengths and Difficulties Questionnaire / 신경정신의학

OBJECTIVES: This study aims to develop a Korean version of the Strengths and Difficulties Questionnaire (SDQ-Kr). METHODS: The Strengths and Difficulties Questionnaire (SDQ) is a brief behavioural screening questionnaire that can be completed by the parents within 5 minutes and used to assess the psychopathology (prosocial behaviour, hyperactivity, emotional problems, conduct problems, and peer problems) of 4-16 year olds. The SDQ was translated into Korean, retranslated back to English, and corrected after discussion with the original developer and trial test. The reliability and validity of the SDQ-Kr was evaluated by working with 347 parents of nonclinical (n=98), pediatric outpatient (n=92), and psychiatric outpatient (n=157) children. RESULTS: Working with 62 parents of nonclinical children, the test-retest reliability of 5 subscales of SDQ-Kr was 0.94-0.84 (p<0.01). For 190 nonclinical and pediatric children, internal consistency of 5 subscales of SDQ-Kr was 0.80-0.50 (Cronba-ch's alpha). Factor analysis generated the five identical factors with the five subscales explaining 49.5% of total variance. For 347 children of nonclinical, pediatric, and psychiatric group, ANOVA showed that any two among the three groups was significantly different in subscales and total difficulties scores, except between pediatric and psychiatric children in emotional problems subscore (p<0.01). The discriminating rate among three groups was 75.5% in discriminant analysis. CONCLUSIONS: The Korean version of SDQ shows very similar psychometric performance to the original SDQ developed by Goodman. This study gives evidence of the usefulness of the SDQ-Kr as a promising screening instrument for epidemiological research and clinical purposes.

Attachment and Behavior Problems in Adolescents: Internalizing and Externalizing Problems / 신경정신의학

OBJECTIVE: The purpose of this study was to examine the relationship between attachment and behavior problems in adolescents. METHOD: A sample of 792 high school students were examined. Revised Adult Attachment Scale, Self-report Attachment Style, Youth Self-Report Child Behavior Checklist (YSR) were used to measure the attachment quality, the attachment pattern and the behavior problems respectively. RESULTS: As to the attachment quality, high score in fear of rejection, low dependability and low intimacy were related to the development of adolescent's internalizing problems. As to the attachment pattern, preoccupied and fearful with attachment experience were linked to the internalizing behavior problems of higher level as well as 'Attention problems' and 'Aggressive behavior' sub-scales of externalizing ones on YSR. CONCLUSION: High fear of rejection, low dependability and low intimacy characterise the insecure attachment. So the insecure attachment might predict the development of all internalizing behavior problems, attention problems and aggressive behavior in adolescents. Also the result suggested that the adolescents classified as Dismissing attachment may have a positive view of the self and may minimize the self reported behavior problems.

Association between Attention Deficit Hyperactivity Disorder and Dopamine Transporter Gene(DAT1) Polymorphism in Korean / 신경정신의학

OBJECTIVES: Study results of association between dopamine transporter gene(DAT1) and attention deficit hyperactivity disorder(ADHD) were not conclusive. Distribution of DAT1 polymorphism is variable according to ethnicity. Ethnic differences in the distribution of DAT1 can be an impediment to apply previous findings to Korean ADHD. This study was to examine the association between DAT1 and ADHD, and the risk allele of ADHD among DAT1 polymorphism in Korean. METHODS: DNA extracted from blood of 100 normal controls and 44 ADHD patients. DAT1 with variable number of tandem repeats(VNTR) were determined using polymerase chain reaction. The differences of allelic frequency distribution and genotype frequency distribution between patient group and control group were tested with Fisher's exact test. The pairs of allele and of genotype with difference between the two groups were selected by Fisher's excat test adjusting p-values with permutation method. Odds ratios of two alleles and of two genotypes between the two groups were computed. RESULTS: There was association between DAT1 and ADHD(genotype: p<0.05, allele: p<0.05. Patients with ADHD were more likely to have 440 base pairs than 480 base pairs comparing to controls (OR=4.46, 95% CI: 1.44-13.75). Patients with ADHD were more likely to have 9/10 genotype than 10/10 genotype comparing to controls(Odd Ration=3.74, 95% Confidence Interval: 1.11-12.61). CONCLUSIONS: We found the association between DAT1 and ADHD, and possible risk allele of Korean ADHD. Replication of the results in larger sample is needed.

A Study of Adolescent Problem Behaviors and Parenting Behaviors / 신경정신의학

OBJECTIVES: The purpose of this study is to evaluate the problem behaviors of adolescents and to discriminate between parenting behaviors of problem behavior groups and those of non-problem behavior group. METHODS: The subjects of this study were 792 high school students in Seoul. We administered 'Parenting Behavior Inventory' and Korean version of Youth Self-Report(K-YSR) to the subjects in order to evaluate the parenting behaviors perceived by adolescents and the problem behaviors of adolescents. We analyzed the relationship between parenting behaviors and problem behaviors. We classified the subjects into problem behavior groups(internalizing group, externalizing group, internalizing-externalizing group) and a non-problem behavior(normal) group. We studied the differences of parenting behaviors among the groups. RESULTS: The results are as follows. 1) There were significant negative correlations between the positive parenting behaviors such as affection, reasoning, and monitoring and the problem behaviors of adolescents. By contrast, there were significant positive correlations between the negative parenting behaviors such as physical abuse, intrusiveness, over-expectation, neglect, and inconsistency and the problem behaviors of adolescents. 2) Adolescents of the internalizing group perceived significantly more parental abuse, intrusiveness, over-expectation, neglect, and inconsistency than those of normal group. Meanwhile, they perceived significantly less affection than normal adolescents. Adolescents of the externalizing group also perceived significantly more parental abuse, intrusiveness, over-expectation, neglect, and inconsistency than those of normal group. Also, they perceived significantly less monitoring than normal adolescents. 3) Adolescents of the internalizing-externalizing group perceived significantly more intrusiveness from both parents than those of either the internalizing or the externalizing groups. Adolescents of the internalizing-externalizing group perceived significantly less affection and more neglect from their mothers than those of the internalizing or the externalizing groups. In addition, adolescents of the internalizing-externalizing group perceived significantly more physical abuse from their fathers than those of the internalizing or the externalizing groups. CONCLUSION: Parenting behaviors such as abuse, intrusiveness, over-expectation, neglect, and inconsistency are associated with both internalizing and externalizing problems. In contrast, our results suggest that parenting behaviors such as affection, monitoring, and reasoning might decrease the various problem behaviors of adolescents.

Environment and Psychological Status in School Refusing Adolescents / 신경정신의학

OBJECTIVES: School refusal can result from various causes; temperament, familial influences, and school experiences have been identified. This study was to compare family, school and psychological functioning in school-refusing adolescents and non-refusing ones. METHODS: Twenty-four school refusing outpatients aged 13-17 years were evaluated from May, 1998 to January, 1999. They completed self-report questionnaires, including Parent Bonding Instrument, Family Environment Scale, Index of Marital Satisfaction, Scales for School-related Distress, Center-for Epidemiological Studies-Depression, The Failure and Criticism Factor of Fear Survey Schedule from Children-revised. Their scores were compared with nonrefusers. RESULTS: The results were as follows: 1) School refusers perceived their family as more independence and achievement-oriented than nonrefusers. 2) School refusers did not differ significantly from nonrefusers in school-related distress. 3) School refusers had more depression than nonrefusers. 4) School refusers claimed more fear of having to go to school, and having to stay after school than nonrefusers. On the other hand, nonrefusers expressed greater apprehension about situations such as Being called on by the teacher, Getting poor grades, Failing a test, and Taking a test. CONCLUSION: The results suggested two postulated mechanisms of school refusals (overprotection and demanding of independence of parents) and possible causes of each result were discussed.

Personality Factor and Defense Machanism in Social Phobia Patients / 신경정신의학

OBJECTIVES: The purpose of this study was to evaluate the characteristics of personality factor and defense mechanism and to compare the difference between non-offensive and offensive types of social phobia patients. METHODS: Study subjects consisted of 28 social phobia patients diagnosed with the criteria of DSM-IV. Data were collected through Sixteen Personality Factor Questionnaire and Ehwa Diagnostic Test of Defense Mechanism. We employed was the independent sample t-test for the analysis. RESULT: Among the personality factor, the shyness/boldness factor scored lower than normal in social phobia patients. Humor drfense scored lower than normal among defense mechanisms. There was no significant correlation between non-offensive and offensive types of social phobia in personality factors and defense mechanisms. CONCLUSIONS: Social phobia patients were shier and less frequently used humor defense than the ordinary people. There was no significant correlation between non-offensive and offensive types of social phobia patients in personality factors and defense mechanisms.

A Study of Personality Factor and Defense Mechanism in Panic Disorder Patients / 신경정신의학

OBJECTIVES: The purpose of this study was to evaluate the characteristics of personality factor and defense mechanism and relationship with depression and social disability. METHODS: Study subjects consisted of 35 panic disorder patients diagnosed with the criteria of DSM-IV. Data were collected through Sixteen Personality Factor Questionnaire, Ehwa Diagnostic Test of Defense Mechanism, Beck Depression Inventory and Sheehan Disability Scale. Statistics employed for the analyses were Pearson correlation and independent sample t-test. RESULTS: In personality factors and defense mechanisms, there were no definitely abnormal range of scores. But, among personality factors, tension/anxiety factor scored high and unstableness/stableness, shyness/boldness and praxernia/atunia were in low range of score. In defense mechanism, somaticzation and acting-out scored high and humor, suppression, altruism, avoidance and rationalization scored low. The mean BDI score was 18.25+/-9.97. The mean score of SDS were 4.88+/-3.11 in work category and 4.57+/-2.92 in social/leasure category. Male patients were significantly correlated with guit-proneness and atuia in personality factor and passive- aggressiveness, projection, denial and show-off in defense mechanism, compared with female patients (p<0.05). The patients' age was correlated with low intelligence in persolity factor and dissociation and anticipation in defense mechanism. It was negatively correlated with show-off (p<0.05). The BDI score was correlated with low intelligence, superego, unstableness, self-conflict, high superego and atunia in personality factor and dissociation and somatization in defense mechanism (p<0.05). There was a significant relationship between BDI score and SDS work category (p<0.05). CONCLUSION: Panic disorder patients show high score of tension/anxiety factor and they frequently use neurotic defense style like somatization. The depressive symptom, which depends on symptom severity, appears to have influence on work category and to cause social disability.

A Case of Clozapine Treatment for Tardive Dystonia in Chronic Schizophrenia / 대한정신약물학회지

Tardive dystonia is an uncommon late side-effect of neuroleptic drug treatment and a difficult condition to treat. We report a single case of tardive dystonia that has successfully responded to clozapine. This patient has undergone more than thirteen years of antipsychotic treatment and developed severe and persistent tardive dystonia. Treatment with benzodiazepine, anticholinergics and muscle relaxant were ineffective in this patient. Thus, clozapine was tried. Treatment with clozapine brought about marked improvement and this remission has been sustained. We reviewed the literatures about successful treatment of tardive dystonia with clozapine. Finally, we recommend a trial of clozapine in adequate doses and for adequate duration on patients with drug-induced tardive dystonia.